[Remote] Clinical Operations Specialist

Note: The job is a remote job and is open to candidates in USA. Mass General Brigham Health Plan is a leading integrated healthcare system focused on providing innovative solutions to enhance member care. The Clinical Operations Specialist oversees daily operational workflows within the Physician Review Unit, ensuring timely and compliant medical review decisions while driving process improvements and collaboration across departments.ResponsibilitiesManages daily case volume in the physician queues and facilitates case assignment as needed, in accordance with TAT and regulatory requirementsCollaborates with data analytics and quality to monitor Medical Director review volumes and quality metrics, including inter-rater reliabilityWorks with the Medical Directors to collect quality concerns regarding cases sent to the unitIdentify bottlenecks in the clinical review lifecycle and implement "lean" strategies to reduce turnaround times and administrative functionsOptimizes physician unit operations by leading workflow design, ensuring regulatory compliance, and embedding changes through standardized documentation and trainingAttends and facilitates cross-functional area case discussion with the Deputy Chief Medical Officer, Senior Medical Director, and other clinical leadershipResponsible for keeping schedules of MDs and assuring coverage, and coordinating the vacation processCollaborates cross-functionally with Utilization Management, Network Management, Provider Relations, and Customer Service to resolve complex cases and escalate provider or contract issuesPerforms other duties as assignedComplies with all policies and standardsSkillsBachelor's Degree requiredAt least 2-3 years of experience working in a health plan environment required, but preferably in Utilization ManagementStrong understanding of utilization management workflows, including physician reviews, prior authorization processes, appeals, peer reviews, and out-of-network (OON) reviews requiredStrong analytical and critical thinking skills, with the ability to interpret clinical data and guidelinesExcellent communication and interpersonal skills, adept at communicating with professionals from many different backgrounds and disciplinesProficiency in healthcare software systems and the Microsoft Office suiteDetail-oriented and organized, with strong problem-solving skillsCommitted to patient-centered care and continuous quality improvementDemonstrated ability to work effectively with Medical Directors, physicians, and senior clinical leadersClinical background with patient care experience preferredProcess improvement experience preferredBenefitsCompetitive salaries and a benefits package with flexible work options, career growth opportunities, and much moreComprehensive benefits, career advancement opportunities, differentials, premiums and bonuses as applicable and recognition programs designed to celebrate your contributions and support your professional growthRemote role that can be done from most US statesReasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employmentCompany OverviewMass General Brigham Health Plan is an insurance company that offers health plans and research for employees in an organization. It was founded in 1986, and is headquartered in Somerville, Massachusetts, USA, with a workforce of 501-1000 employees. Its website is https://www.massgeneralbrighamhealthplan.org.